Key-words:
Complications - laparotomy - midline incision - small bite closure - suture technique
Introduction
Midline incisions are the most commonly used laparotomy incision[[1]] due to ease and speed of access, less bleeding, no intervening muscles, and subsequent
mass closure. The postoperative wound site complications after laparotomy are of much
concern and worry for a general surgeon. These complications include surgical site
infection (SSI), wound dehiscence, chronic discharge, and delayed complication of
incisional hernia. SSIs are a significant complication of emergency surgery and the
second most common nosocomial infection, accounting for 17% of all healthcare-associated
infections among hospitalized patients. The Centers for Disease Control and Prevention
classifies SSIs as superficial incisional, deep incisional, and organ-space, depending
on the depth of the infection at the surgical site.[[2]] Clean and clean-contaminated wounds have a low risk of SSI, and contaminated and
dirty wounds are highly likely to develop SSIs. Besides the nature of the wound, the
chances of developing an SSI after surgery depends upon host factors (malnutrition,
metabolic disease, immunosuppression). Furthermore, this is influenced by the virulence
of the infective agent, vascularity and health of the invaded tissue, presence of
dead or foreign tissue, and use of antibiotics during the decisive period.[[3]]
SSI after midline laparotomy is the most crucial risk factor for wound dehiscence
and the development of an incisional hernia. Wound dehiscence is a complication of
elective and emergency laparotomy with incidence rates of 1%–3% in elective surgery
and 5%–50% in emergency operations. After primary midline laparotomy, the reported
incidence of incisional hernia is 5%–20% in the literature.[[4]] Efforts have been made to overcome and reduce postoperative complications, decrease
morbidity, and increase the quality of life. The proper operating theatre sterilization
and disinfection methods, preoperative antibiotic prophylaxis, clipping of hair, and
proper surgical skin preparation and delayed wound closure have drastically reduced
the incidence of wound site complications.
Further, the different innovations in techniques of laparotomy closure and quality
of suture material used have a profound effect on postoperative wound site complications.
The long continuous stitches are associated with higher rates of SSI and incisional
hernia.[[5]],[[6]] We aimed to compare the two suture patterns (small bites vs. large bites) for fascial
closure in midline abdominal wounds and their effect on postoperative wound site complications.
Materials and Methods
This study is a prospective comparative observational study in which midline abdominal
wound closure was performed on 324 patients in the Department of Surgery, Government
Medical College Srinagar between 2015 and 2019. All the patients between 18 and 70
years of age of either sex and underwent any abdominal surgery through midline incision
for various indications in either elective or emergency settings were included in
the study. Patients with a history of abdominal surgery and patients with medical
comorbidities (T2DM, Chronic Liver or kidney disease, connective tissue disorders)
were excluded. After a thorough history and clinical examination, all the patients
were subjected to baseline and other relevant investigations to reach a definitive
diagnosis. A single preoperative dose of the 3rd generation cephalosporin was used
in all the subjects before the induction of anesthesia and continued postoperatively
as per the patient's clinical status. On-table shaving of hair with a sterilized blade
was done in all our cases. We used 10% povidone-iodine as an anti-septic solution
to prepare the area, which included nipples to the mid-thighs. Proper sterilized green
drapes were used for covering the operative area.
Patients were divided into two groups using computer-generated random numbers based
on the closure techniques; Group A included patients who underwent midline wound closure
with large tissue bites (10 mm from the wound edge and 10 mm apart and Group B with
small tissue bites (5–7 mm from the wound edge and 5–7 mm apart) and included only
the aponeurosis in the stitches without peritoneum. A continuous, single-layer monofilament
suture (No. 1 polypropylene) on a round body needle was used in both groups to close
the abdomen. The skin was closed as a separate layer with interrupted vertical mattress
silk sutures. Postoperatively, all the patients were strictly monitored in our surgical
ward and examined for the presence or absence of any wound site complications. Patients
were invited for follow-up at out-patient-department fortnightly for the first 2 months
and, after that, 6-monthly after surgery. All the patients had a clinical examination
and ultrasonography abdomen (case-to-case basis) on follow-up visits.
Statistical analysis
The statistical analysis was performed using SPSS software (SPSS version 22, IBM,
Armonk, NY, USA). The mean and frequency were calculated using exile table 10, and
the P values were considered statistically significant if ≤ 0.05.
Results
A total of 324 patients were included in the study. Two hundred and two (62.35%) patients
underwent midline wound closure with large bites, and 122 (37.75%) had small bite
closure. Males (84.56%) outnumbered the females (15.43%) with M: F ratio of 5.48.
The preponderance of males could be due to heavy smoking, irregular meals, spicy meals
and outdoor life, and higher trauma and blast injuries rates in this conflict zone.
A maximum number of patients were between 40 and 49 years of age ((34.57%), followed
by 30–39 years (32.72%), 19–29 years (14.51%), 50–59 years (5.86%), and 60–70 years
(5.86%). The mean age in large tissue bite closure was 38.25 years, while 40.69 years
in small bite closure. Overall mean age in the study population was 39.17 years. Two
hundred and thirty-three patients (71.91%), including 138 (68.32%) patients in the
large bite group and 95 (77.86%) in the small bite group, were operated on in an emergency
setting. There was no statistically significant difference between the two groups
concerning age, sex, albumin levels, body mass index (BMI), and type of surgery [[Table 1]].
Table 1: Study population characteristics
About 29.6% of patients developed SSIs, and 12.7% had wound dehiscence. 19.14% of
patients had minor SSI and 11.1% of subjects had major SSI. Seventy-two (35.6%) patients
out of 202 patients in the large tissue bite group, and 24 (19.7%) patients out of
122 in small bite closure developed SSI. The difference was found to be statistically
significant with a P value of 0.002. The patients were managed by culture-specific
antibiotics, wound care, and twice-daily anti-septic dressings. Infected sutures were
removed to allow the pus to be evacuated completely. Thorough debridement and irrigation
with normal saline, betadine, and antibiotics were made. Some patients with major
SSI were subjected to secondary drainage procedures. Thirty-two (15.84%) patients
in the large tissue bite group and 9 (7.38%) patients in small tissue bite developed
wound dehiscence. The difference was statistically insignificant, with a P value of
0.29. All wound dehiscence patients underwent closure with tension sutures under general
anesthesia. None of them developed any further complications in immediate follow-up.
We found significantly less incisional hernia in small bites techniques than large
bites techniques (P = 0.00001). Fifty-four (26.73%) out of 202 patients in the large
tissue bite group, while only 6 (4.92%) patients in small tissue bites developed an
incisional hernia [[Table 2]].
Table 2: Wound-site complications
Discussion
General surgeons commonly use the midline incision for wide and rapid access to the
general peritoneal cavity. Postoperative wound site complications are a significant
source of morbidity after midline laparotomy. After laparotomy, the incidence of wound
dehiscence and incisional herniae are 4% and 5%–30%, respectively, resulting in increased
pain, prolonged hospitalization, reduced quality of life, increased healthcare burden
and cost, and enhance morbidity rates.[[7]],[[8]],[[9]],[[10]] Different innovations in techniques of closure of midline laparotomy incisions
have a profound effect on preventing postoperative complications. The ideal technique
is the one with reduced incidence of SSI, wound dehiscence, incision hernia, and,
therefore, a better quality of life. A small bites technique with a suture length
to wound length ratio of at least 4:1 is the current recommended method of fascial
closure.[[11]] Millbourn et al.[[12]] demonstrated that small bite closure of midline incision resulted in significant
less incisional hernias (5.6% vs. 18.0%; P = 0.001) and less SSIs (5.2% vs. 10.2%;
P = 0.02). The objective of this study was to compare the suture techniques (small
bite closure vs. large bite closure) and their effect on the incidence of postoperative
wound site complications after midline laparotomy in our medical college hospital.
In our study, a total of 324 patients, 202 (62.35%) patients underwent midline wound
closure with large bites, and 122 (37.75%) had small bite closure. Males (84.56%)
outnumbered the females (15.43%) with M: F ratio of 5.48. The more preponderance of
males could be due to heavy smoking, spicy meals, outdoor life, and higher trauma,
and blast injuries rates in this conflict zone. A maximum number of patients were
between 40 and 49 years of age ((34.57%) and the mean age in the study population
was 39.17 years. There was no statistical difference between the two groups concerning
age, sex, albumin levels, and BMI and these characteristics were similar in both the
groups. Our findings are concordant with those of Millbourn et al.[[12]]
Wound infection occurs when the suture site gets contaminated with microorganisms.
Signs that a surgical wound has been infected include pain, warmth, redness around
the wound site, and unexplained fever. In our study, 72 (35.64%) patients in the large
tissue bite group and 24 (19.67%) patients in small tissue bite developed SSI. The
difference was found to be statistically significant with a P value of 0.002. The
patients with minor SSI were treated with culture-specific antibiotics, wound care,
and twice-daily anti-septic dressings. Infected sutures were removed to allow the
pus to be evacuated completely. Thorough debridement and irrigation with normal saline,
betadine, and antibiotics were made. Some patients with major SSI were subjected to
secondary drainage procedures. These findings were compared with the study of de Vries
et al.[[13]]
Incisional hernia and wound dehiscence are notorious complications of midline laparotomy
and a substantial cause of morbidity. Wound dehiscence refers to the premature splitting
or bursting along the suture lines secondary to poor wound healing. Incisional hernia
is the one that develops at previous surgical scar as a result of improper healing
of fascial tissues. Clinically, it may present as a simple bulge over the operative
scar on straining or sometimes as intestinal obstruction or strangulation. Acute wound
failure (abdominal dehiscence) primarily develops 7–10 days postoperatively and may
occur in approximately 1% to 3% of subjects who undergo the abdominal operation.[[14]] Many factors, including patient-related factors, technical error in fascial closure,
local wound factors, and type of surgery, may contribute to wound dehiscence. The
incisional hernias are twice as common in women as in men and account for 15% to 20%
of all abdominal wall hernias.[[14]] The incidence of incisional hernia ranges from 3% to 20% after midline laparotomy.
This rate doubles if the operation is associated with SSI.[[14]] In our study, wound dehiscence and incisional herniae were 9.6% and 18.5%, respectively.
About 15.8% of patients in large bites technique and 7.4% of patients in small bites
technique developed wound dehiscence. 26.7% of patients in the large bite closure
group, while only 4.9% of patients in the small bite closure group developed an incisional
hernia. The difference was statistically significant (P = 0.00001). In the present
study, SSI wound dehiscence and the incisional hernia were high. This can be attributed
to several factors. Many patients were operated on in emergency settings. Furthermore,
the poor setup of hospitals in low-income countries lacking standard setup to maintain
strict asepsis guidelines), poor hygiene of patients in developing countries, and
delayed presentation of our patients due to late referral from peripheral centers.
In a systemic review by Rene H. Fortelny in 2018, the small bites technique results
in significantly less incisional hernias than a large bites technique in an elective
midline wound closure.[[15]] The incidence of incisional hernia is significantly lower in small-bite closure
than large-bite closure in other studies found in the literature.[[13]],[[16]]
Conclusion
A midline incision closed with small tissue bites is associated with lower postoperative
wound site complications. This technique substantially reduces SSIs and wound dehiscence
and results in a low incidence of incisional hernia. The conventional practice of
large tissue bites should be changed to small-bite closure to avoid patient suffering
and health-care burden in a low-resource setup like ours. The accident-emergency and
general surgery residents, in particular, should be made familiar with this technique
to avoid postoperative wound site complications and improve the quality of postoperative
life.
Authors contributions
All the named authors fulfilled the ICMJE authorship criteria by substantial contribution
to the conception and designing, data collection, and data interpretation. They all
contributed to the drafting and revising of the manuscript for intellectual content
and approval of its final version.
Compliance with ethical principles
The study was approved by Institutional Ethical Committee (IEC) of the Government
Medical College, Jammu and Kashmir. Written informed consent was taken from all the
patients before the procedure.
Reviewers:
Najat Amharar (Abu Dhabi, UAE)
Ali Ghellai (Tripoli, Libya)
Editors:
Elmahdi A Elkhammas (Columbus OH, USA)
